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Kierkegaard famously said life is lived forward and understood backwards. What is true for life is also true for pandemics and it is tempting to look at the dawning days of COVID-19 through the prism of reflection. But to do so would be to lose the lived experience of those who had to make fraught choices during the initial surge of the pandemic. What happened during March and April 2020 should not be obscured by a post hoc analysis informed by what we learned about the SARS-COV-2 virus or about ourselves since those early days. That early history, unsanitized as it was, is essential to framing subsequent discourse. As an academic physician charged with coordinating a clinical ethics service at a major academic medical center during the spring surge in New York City, I can attest that what happened during the spring of 2020 in New York City bears remembrance, not only to honor those who served – and died – but just as importantly, to inform clinical care and public policy. Those lessons were hard won and it would be unfortunate to lose them through the gauzy haze of memory.
If treatments or vaccines for COVID-19 are scarce, should patients pre-existing disabilities be relevant to allocating those interventions? In allocating scarce life-sustaining treatments, some crisis standards of care have explicitly deprioritized or even categorically excluded individuals with underlying conditions that are understood to limit probability of survival, life expectancy or the quality of life. Others have used scoring systems that may work to the disadvantage of people with certain disabilities. All of these systems have faced opposition from disability rights advocates. But advocates have not opposed proposals to prioritize individuals with pre-existing disabilities for receipt of a vaccine. This chapter offers a dialogue on the legal and ethical questions presented by the impact of allocation policies on individuals with disabilities. One of the authors has served as counsel to advocacy organizations that have challenged disability-based crisis standards of care; the other author has defended evidence-based use of disability in allocating scarce life-sustaining treatments.
The unfolding of the COVID-19 pandemic provided the American public with a master class on health care inequality and how vulnerability to ill health is created. Black people and disabled people, along with folks in other marginalized communities, have suffered disproportionately from the coronavirus’s ravages of sickness and death, as well as its economic burden.
Plans for allocation of scarce life-sustaining resources during the coronavirus disease 2019 (COVID-19) pandemic often include triage teams, but operational details are lacking, including what patient information is needed to make triage decisions.
A Delphi study among Washington state disaster preparedness experts was performed to develop a list of patient information items needed for triage team decision-making during the COVID-19 pandemic. Experts proposed and rated their agreement with candidate information items during asynchronous Delphi rounds. Consensus was defined as ≥80% agreement. Qualitative analysis was used to describe considerations arising in this deliberation. A timed simulation was performed to evaluate feasibility of data collection from the electronic health record.
Over 3 asynchronous Delphi rounds, 50 experts reached consensus on 24 patient information items, including patients’ age, severe or end-stage comorbidities, the reason for and timing of admission, measures of acute respiratory failure, and clinical trajectory. Experts weighed complex considerations around how information items could support effective prognostication, consistency, accuracy, minimizing bias, and operationalizability of the triage process. Data collection took a median of 227 seconds (interquartile range = 205, 298) per patient.
Experts achieved consensus on patient information items that were necessary and appropriate for informing triage teams during the COVID-19 pandemic.
This paper examines several decision-making models that have been proposed to limit the use of CPR for COVID-19 patients. My main concern will be to assess proposals for the implementation of unilateral DNRs — i.e., orders to withhold CPR without the agreement of patients or their surrogates.
As the coronavirus pandemic intensified, many communities in the United States experienced shortages of ventilators, intensive care beds, and other medical supplies and treatments. Currently, there is no single national response to provide guidance on allocation of scarce health care resources. Accordingly, states have formulated various “triage protocols” to prioritize those who will receive care and those who may not have the same access to health care services when the population demand exceeds the supply. Triage protocols address general concepts of “fairness” under accepted medical ethics rules and the consensus is that limited medical resources “should be allocated to do the greatest good for the greatest number of people.”1 The actual utility of this utilitarian ethics approach is questionable, however, leaving many questions about what is “fair” unanswered. Saving as many people as possible during a health care crisis is a laudable goal but not at the expense of ignoring patients’s legal rights, which are not suspended during the crisis. This Article examines the triage protocols from six states to determine whose rights are being recognized and whose rights are being denied, answering the pivotal question: If there is potential for disparate impact of facially neutral state triage protocols against Black Americans and other ethnic groups, is this legally actionable discrimination? This may be a case of first impression for the courts to resolve.
“[B]lack Americans are 3.5 times more likely to die of COVID-19 than [W]hite Americans … . Latinx people are almost twice as likely to die of the disease, compared with [W]hite people.”
“Our civil rights laws protect the equal dignity of every human life from ruthless utilitarianism … . HHS is committed to leaving no one behind during an emergency, and this guidance is designed to help health care providers meet that goal.” — Roger Severino, Office of Civil Rights Director, U.S. Department of Health and Human Services.
State governments and hospital facilities are often unprepared to handle a complex medical crisis, despite a moral and ethical obligation to be prepared for disaster. The 2019 novel coronavirus disease (COVID-19) has drawn attention to the lack of state guidance on how hospitals should provide care in a crisis. When the resources available are insufficient to treat the current patient load, crisis standards of care (CSC) are implemented to provide care to the population in an ethical manner, while maintaining an ability to handle the surge. This Editorial aims to raise awareness concerning a lack of preparedness that calls for immediate correction at the state and local level.
Analysis of state guidelines for implementation of CSC demonstrates a lack of preparedness, as only five states in the US have appropriately completed necessary plans, despite a clear understanding of the danger. States have a legal responsibility to regulate the medical care within their borders. Failure of hospital facilities to properly prepare for disasters is not a new issue; Hurricane Katrina (2005) demonstrated a lack of planning and coordination. Improving disaster health care readiness in the United States requires states to create new policy and legislative directives for the health care facilities within their respective jurisdictions. Hospitals should have clear directives to prepare for disasters as part of a “duty to care” and to ensure that the necessary planning and supplies are available to their employees.
In 2009, the Institute of Medicine published guidelines for implementation of Crisis Standards of Care (CSC) at the state level in the United States (US). Based in part on the then concern for H1N1 pandemic, there was a recognized need for additional planning at the state level to maintain health system preparedness and conventional care standards when available resources become scarce. Despite the availability of this framework, in the years since and despite repeated large-scale domestic events, implementation remains mixed.
Coronavirus disease 2019 (COVID-19) rejuvenates concern for how health systems can maintain quality care when faced with unrelenting burden. This study seeks to outline which states in the US have developed CSC and which areas of care have thus far been addressed.
An online search was conducted for all 50 states in 2015 and again in 2020. For states without CSC plans online, state officials were contacted by email and phone. Public protocols were reviewed to assess for operational implementation capabilities, specifically highlighting guidance on ventilator use, burn management, sequential organ failure assessment (SOFA) score, pediatric standards, and reliance on influenza planning.
Thirty-six states in the US were actively developing (17) or had already developed (19) official CSC guidance. Fourteen states had no publicly acknowledged effort. Eleven of the 17 public plans had updated within five years, with a majority addressing ventilator usage (16/17), influenza planning (14/17), and pediatric care (15/17), but substantially fewer addressing care for burn patients (9/17).
Many states lacked publicly available guidance on maintaining standards of care during disasters, and many states with specific care guidelines had not sufficiently addressed the full spectrum of hazard to which their health care systems remain vulnerable.
To identify key decisions along the continuum of care (conventional, contingency, and crisis) and the critical triggers and data elements used to inform those decisions concerning public health and health care response during an emergency.
A classic Delphi method, a consensus-building survey technique, was used with clinicians around Washington State to identify regional triggers and indicators. Additionally, using a modified Delphi method, we combined a workshop and single-round survey with panelists from public health (state and local) and health care coalitions to identify consensus state-level triggers and indicators.
In the clinical survey, 122 of 223 proposed triggers or indicators (43.7%) reached consensus and were deemed important in regional decision-making during a disaster. In the state-level survey, 110 of 140 proposed triggers or indicators (78.6%) reached consensus and were deemed important in state-level decision-making during a disaster.
The identification of consensus triggers and indicators for health care emergency response is crucial in supporting a comprehensive health care situational awareness process. This can inform the creation of standardized questions to ask health care, public health, and other partners to support decision-making during a response. (Disaster Med Public Health Preparedness. 2017;11:467–472)
Based on background information in this special issue of the journal, possible triage recommendations for the first 4 days following a nuclear detonation, when response resources will be limited, are provided. The series includes: modeling for physical infrastructure damage; severity and number of injuries; expected outcome of triage to immediate, delayed, or expectant management; resources required for treating injuries of varying severity; and how resource scarcity (particularly medical personnel) worsens outcome. Four key underlying considerations are: 1.) resource adequacy will vary greatly across the response areas by time and location; 2.) to achieve fairness in resource allocation, a common triage approach is important; 3.) at some times and locations, it will be necessary to change from “conventional” to “contingency” or “crisis” standards of medical care (with a resulting change in triage approach from treating the “sickest first” to treating those “most likely to survive” first); and 4.) clinical reassessment and repeat triage are critical, as resource scarcity worsens or improves. Changing triage order and conserving and allocating resources for both lifesaving and palliative care can maintain fairness, support symptomatic care, and save more lives. Included in this article are printable triage cards that reflect our recommendations. These are not formal guidelines. With new research, data, and discussion, these recommendations will undoubtedly evolve.
(Disaster Med Public Health Preparedness. 2011;5:S111-S121)
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